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The Big Picture, The Big Opportunity: Covering the Uninsured Overall, in Georgia: About 1.9 million uninsured; one-fifth of the population and one- fourth of working-age adults Georgia consistently ranks in the top 10 among the states in number and percentage of uninsured Overall distribution of the uninsured in Georgia by income: <100% FPL……. 45% 100-138% FPL… 12% 139-250% FPL… 23% 251-399% FPL…. 11% 400% FPL+ 8%......9% Source: CPS data, 2-year average 09 – 10 (Kaiser State Health Facts)

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ACA: Overall Approach to Coverage Everyone is eligible for something (citizens and most legal immigrants) Maintain employment-based health insurance system Expand Medicaid for low-income individuals and families Restructure the individual and small group health insurance marketplace through exchanges and new regulations Individual mandate

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Why Expand Medicaid? People with low-incomes disproportionately lack access to job-based health insurance (nationally, 28% of predominately low-wage firms offer v. 77% of predominately high-wage firms)* Purchasing a private, individual policy is cost-prohibitive for people with very low incomes Medicaid is an existing program; many states have used it as a vehicle to expand coverage for low-income families over the past 20 years * Source: Kaiser Family Foundation Employer Health Benefits 2012 Survey

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Why Expand Medicaid, contd? Improves health access and outcomes: Oregon health insurance experiment: Medicaid more likely to have a usual source of care and to get preventive care than their uninsured counterparts (Source: National Bureau of Economic Research) New England Journal of Medicine study: states that expanded Medicaid saw lower mortality rates than neighboring states that did not, after controlling for a range of factors (Source: New England Journal of Medicine) Reduces the burden of uncompensated care Federal funds coming into the health care economy have a stimulative effect: economic impact of $72 billion ($16 in impact from federal dollars for every $1 in state funds) (Source: AJC, University of Georgia) * Source: Kaiser Family Foundation Employer Health Benefits 2012 Survey

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Who would be newly eligible for Medicaid? Creates a new eligibility category for Medicaid based solely on income Eligible individuals include those with incomes up to 138% FPL ($15,028 for an individual or $25,571 for a family of 3), Medicaid- eligible regardless of category Estimated 645,000 – 900,000 new Medicaid enrollees by 2019 (mostly childless adults) in Georgia

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Medicaid Expansion, contd Expansion initially financed with 100% federal dollars (2014-2016) and then scales down such that by 2020 and thereafter the expansion population is 90% federally financed Increased enrollment will lead to a 28.9% increase in federal spending and 2.7% increase in state spending relative to baseline (Source: KFF) Temporary increase in Medicaid reimbursement rates for primary care providers to parity with Medicare rates (federally financed) for two years, beginning this year

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What did SCOTUS say about Medicaid? The carrot is constitutional, but not the stick It is overly coercive to withhold all of a states Medicaid funds for failing to expand to 138% FPL The Medicaid expansion stands but HHS can only enforce it by withholding funds for the expansion population if a state does not adopt it, making it effectively optional for states

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What are the implications for coverage? Congress authorized tax credits for the purchase of private health insurance through the exchange only for people with incomes above the poverty level If states expand Medicaid, they retain the spirit of the ACA; everyone has a pathway to coverage If a state chooses not to expand Medicaid, inequities within states and disparities across states will ensue

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Cover Georgia Good for consumers, good for health care system, good for the economy Can improve access to health care; can help ameliorate disparities Georgia taxpayers pay federal income taxes, and this money will go to other states if it doesnt come back to Georgia No deadline for states to join and states can withdraw from the expansion if it isnt working for them